INVITED COMMENTARY Continously growing demand for perfect surgery calls hypoplasia in Treacher-Collins syndrome seems to be mostly for special training, sophisticated tools and mod- rather inessential. The above cannot be said however, in ern equipment. The need for anatomic studies is less ev- relation to severe HCFM, where the final step after ident however, because this field of medicine seems to TMJ and mandibular ramus reconstruction consists as a be well known and minutely explored. As it may be true rule of free flap transfer. Transplanted tissue when added with reference to the most often invaded parts of the hu- to the fullness of the under developed side may produce man body, there are still some areas considered in the past unpleasant chubby appearance. Therefore the unilateral as less important and therefore not thoroughly examined. BFP resection should allow for more pronounced, sym- The anatomical re-explorations are stimulated by new sur- metric free flap reduction. The similar approach can also gical methods, increased research potential or-less fre- be beneficial for neglected TMJA, since removal of BFP quently-by hunger of knowledge mixed with curiosity excess from unaffected side (about 4.000 mm ) should and disbelief in dogma. contribute to better symmetry. In this elegant study, thanks to the use of modern, so- My next remark relates to severe microgenia. Accord- phisticated technique, the authors were able to elucidate ing to my own clinical observations, the chubby midface some misunderstandings and unjustified statements con- appearance is produced by both unstreached tissues and cerning the volume changes of the buccal fat pad (BFP) excessively developed BFP. Therefore, after orthodontic in various age groups. As a result of it, quite common be- surgery, in selected cases bilateral buccal fat resection lief that the BFP is larger in the infant, and the size of it should be taken into consideration, as reasonable and use- decreases with age, should be revised and corrected. ful refinement procedure. The measurements of volume differences between the The question whether prolonged immobilization and both sides of the same individuals with unilateral malfor- impaired function of muscles may produce the BFP vol- mations, diseases and truma seems to be no less impor- ume reduction, should be probably more elucidated by ex- tant, although not fully explained so far. While the signif- amination of patients with long-lasting paralysis of the fa- icant differences of volumes between affected and non af- cial nerve. If so, the use of BFP as a gliding tissue for fected sizes in truma and TMJ diseases cannot be regard- temporalis muscle transfer according to LabbØ method ed as unexpected, the minor, not significant volumes dif- [1] should be taken into consideration when planning ferences in unilateral clefts seems to be less convincing the above procedure. and possibly demand further elucidation. The authors' ex- In conclusion the authors should be commended for in- planation referring to early restoration of the muscle func- spiring and thorough study all the more so, as the detailed tion is reasonable indeed, but in order to obtain an undis- anatomy of BFP should not be regarded as purely aca- putable answer it would be good to mention what kind of demic, but also practical knowledge which should allow clefts were examined, because due to differences between for more sophisticated, precise surgery. partial and complete clefts, the separate assessment of the last group could be more informative. When discussing the above problem, I would be glad References to hear in the future about similar study on BFP volume 1. LabbØ D (1997) Myoplastie d'allongement du temporalis et re- in so called rare clefts and syndromes. According to my animation des leveres, notre technique. Ann Chir Plast Esthet own clinical observations made e.g. during the treatment 42:44±47 of over 70 Treacher-Collins and hemicraniofacial mi- crosomias (HCFM), there were quite important abnormal- K. Kobus ities of BPF which deserve thorough examination. Hospital of Plastic Surgery From the practical point of view, due to great demand ul. Kos Âcielna 1, for tissue augmentation, an assessment of presumed BFP PL-57-320 Polanica Zclroj, Poland European Journal of Plastic Surgery Springer Journals


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Copyright © 1999 by Springer-Verlag Berlin Heidelberg
Medicine & Public Health; Plastic Surgery
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